Research progress on valgus impacted proximal humeral fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LI Bo ,  CHANG Shimin , HU Sunjun , DU Shouchao , XIONG Wenfeng

Department of Orthopaedics, Yangpu Hospital, Tongji University, Shanghai, 200090, P. R. China;

Corresponding author：

CHANG Shimin, Email: shiminchang11@aliyun.com

Keywords：

Proximal humerus fracture; valgus impacted fracture; definition; classification; treatment

DOI：

10.7507/1002-1892.202308062

Video：

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Objective To review the advancement made in the understanding of valgus impacted proximal humeral fracture (PHF). Methods The domestic and foreign literature about the valgus impacted PHF was extensively reviewed and the definition, classification, pathological features, and treatment of valgus impacted PHFs were summarized. Results PHF with a neck shaft angle ≥160° is recognized as a valgus impacted PHF characterized by the preservation of the medial epiphyseal region of the humeral head, which contributes to maintenance of the medial periosteum’s integrity after fracture and reduces the occurrence of avascular necrosis. Therefore, the valgus impacted PHF has a better prognosis when compared to other complex PHFs. The Neer classification designates it as a three- or four-part fracture, while the AO/Association for the Study of Internal Fixation (AO/ASIF) categorizes it as type C (C1.1). In the management of the valgus impacted PHF, the selection between conservative and surgical approaches is contingent upon the patient’s age and the extent of fracture displacement. While conservative treatment offers the advantage of being non-invasive, it is accompanied by limitations such as the inability to achieve anatomical reduction and the potential for multiple complications. Surgical treatment includes open reduction combined with steel wire or locking plate and/or non-absorbable suture, transosseous suture technology, and shoulder replacement. Surgeons must adopt personalized treatment strategies for each patient with a valgus impacted PHF. Minimally invasive surgery helps to preserve blood supply to the humeral head, mitigate the likelihood of avascular necrosis, and reduce postoperative complications of bone and soft tissue. For elderly patients with severe comminuted and displaced fractures, osteoporosis, and unsuitable internal fixation, shoulder joint replacement is the best treatment option. Conclusion Currently, there has been some advancement in the classification, vascular supply, and management of valgus impacted PHF. Nevertheless, further research is imperative to assess the clinical safety, biomechanical stability, and indication of minimally invasive technology.

Citation： LI Bo, CHANG Shimin, HU Sunjun, DU Shouchao, XIONG Wenfeng. Research progress on valgus impacted proximal humeral fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(1): 107-112. doi: 10.7507/1002-1892.202308062 Copy

1.	Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand, 2001, 72(4): 365-371.
2.	Neer CS. Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg, 2002, 11(4): 389-400.
3.	DeFranco MJ, Brems JJ, Williams GR, et al. Evaluation and management of valgus impacted four-part proximal humerus fractures. Clin Orthop Relat Res, 2006, 442: 109-114.
4.	Neer CS 2nd. Displaced proximal humeral fractures. Ⅰ. Classification and evaluation. J Bone Joint Surg (Am), 1970, 52(6): 1077-1089.
5.	Stableforth PG. Four-part fractures of the neck of the humerus. J Bone Joint Surg (Br), 1984, 66(1): 104-108.
6.	Jakob RP, Miniaci A, Anson PS, et al. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg (Br), 1991, 73(2): 295-298.
7.	Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma, 2018, 32 Suppl 1: S1-S170.
8.	Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg, 2004, 13(4): 427-433.
9.	Laing PG. The arterial supply of the adult humerus. J Bone Joint Surg (Am), 1956, 38-A(5): 1105-1116.
10.	Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg (Am), 1990, 72(10): 1486-1494.
11.	Brooks CH, Revell WJ, Heatley FW. Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study. J Bone Joint Surg (Br), 1993, 75(1): 132-136.
12.	Panagopoulos AM, Dimakopoulos P, Tyllianakis M, et al. Valgus impacted proximal humeral fractures and their blood supply after transosseous suturing. Int Orthop, 2004, 28(6): 333-337.
13.	Resch H, Beck E, Bayley I. Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg, 1995, 4(2): 73-80.
14.	Resch H, Povacz P, Fröhlich R, et al. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg (Br), 1997, 79(2): 295-300.
15.	Foruria AM. Plate fixation of proximal humerus fractures: how to get it right and future directions for improvement. Curr Rev Musculoskelet Med, 2023, 16(10): 457-469.
16.	Solberg BD, Moon CN, Franco DP, et al. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma, 2009, 23(2): 113-119.
17.	Robinson CM, Longino D, Murray IR, et al. Proximal humerus fractures with valgus deformity of the humeral head: the spectrum of injury, clinical assessment and treatment. J Shoulder Elbow Surg, 2010, 19(7): 1105-1114.
18.	Leyshon RL. Closed treatment of fractures of the proximal humerus. Acta Orthop Scand, 1984, 55(1): 48-51.
19.	Mills HJ, Horne G. Fractures of the proximal humerus in adults. J Trauma, 1985, 25(8): 801-805.
20.	Neer CS 2nd. Displaced proximal humeral fractures. Ⅱ. Treatment of three-part and four-part displacement. J Bone Joint Surg (Am), 1970, 52(6): 1090-1103.
21.	Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. J Bone Joint Surg (Am), 2004, 86-A Suppl 1(Pt 2): 143-155.
22.	Atalar AC, Eren I, Uludağ S, et al. Results of surgical management of valgus-impacted proximal humerus fractures with structural allografts. Acta Orthop Traumatol Turc, 2014, 48(5): 546-552.
23.	王传舜, 李豪青, 伍凯, 等. 肱骨近端锁定接骨板结合异体骨植骨治疗外翻嵌插型四部分肱骨近端骨折. 中华创伤骨科杂志, 2013, 15(10): 909-911.
24.	菅振, 周建华, 吴良浩, 等. 解剖锁定钢板结合注射式人工骨植骨治疗老年肱骨近端外展嵌插四部分骨折. 中华肩肘外科电子杂志, 2020, 8(2): 140-145.
25.	Gunst S, Walch G, Nové-Josserand L. Percutaneous fixation of valgus displaced fracture of the proximal humerus using a single screw. Orthop Traumatol Surg Res, 2018, 104(1): 67-70.
26.	Fang C, Kwek EBK. Self-reducing proximal humerus fractures. J Orthop Surg (Hong Kong), 2017, 25(2): 2309499017717180.
27.	Bekmezci T, Çepni SK. Subgroups and differences of fixation in 3-part proximal humerus fractures. Ulus Travma Acil Cerrahi Derg, 2023, 29(5): 627-632.
28.	李红军, 刘永国, 王建军, 等. 解剖锁定钢板内固定治疗肱骨近端外翻嵌插型骨折的疗效观察. 中国修复重建外科杂志, 2016, 30(3): 359-362.
29.	王华松, 杨晨曦, 吴刚, 等. 经三角肌入路锁定钢板内固定治疗老年外展嵌插型肱骨近端骨折. 中华创伤杂志, 2020, 36(3): 228-232.
30.	李波, 熊文峰, 张世民. 锁定钢板治疗肱骨近端骨折中螺钉穿透关节面的研究进展. 中国修复重建外科杂志, 2021, 35(4): 403-408.
31.	Panagopoulos A, Tatani I, Yannis S, et al. Transosseous suture fixation of true 4-part valgus impacted fractures of the proximal humerus: Clinical and radiological outcome in 49 patients. Open Orthop J, 2018, 12: 41-52.
32.	Miquel J, Martínez R, Santana F, et al. Surgical treatment of proximal humeral fractures with the transosseous suture fixation. J Orthop Surg Res, 2021, 16(1): 405.
33.	Scheer JH, Tillander BM, Dånmark I, et al. Solely sutures is a reliable fixation for valgus-impacted proximal humeral fractures. J Clin Orthop Trauma, 2021, 15: 130-135.
34.	Ju J, Ma M, Ding Z, et al. A transosseous suture as an alternative to suture anchor on anterior-avulsion greater tuberosity fragment fixation in Neer three-part proximal humeral fracture: A biomechanical study. Orthop Surg, 2023, 15(8): 2132-2137.
35.	Srinivasan RC, Wright JO, Hao KA, et al. Two-year outcomes of the reverse humeral reconstruction prosthesis. J Shoulder Elbow Surg, 2023, 32(6S): S75-S84.
36.	Han PF, Yang S, Wang YP, et al. Reverse shoulder arthroplasty vs. hemiarthroplasty for the treatment of osteoporotic proximal humeral fractures in elderly patients: A systematic review and meta-analysis update. Exp Ther Med, 2022, 24(4): 637.
37.	Filho GDRM, Amaral MVG. Shoulder arthroplasty for the treatment of proximal humeral fractures: Current concepts. Rev Bras Ortop (Sao Paulo), 2021, 57(4): 529-539.
38.	Weber S, Grehn H, Hutter R, et al. Shoulder arthroplasty for proximal humeral fracture treatment: a retrospective functional outcome analysis. Eur J Orthop Surg Traumatol, 2023, 33(5): 1581-1589.

1. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand, 2001, 72(4): 365-371.
2. Neer CS. Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg, 2002, 11(4): 389-400.
3. DeFranco MJ, Brems JJ, Williams GR, et al. Evaluation and management of valgus impacted four-part proximal humerus fractures. Clin Orthop Relat Res, 2006, 442: 109-114.
4. Neer CS 2nd. Displaced proximal humeral fractures. Ⅰ. Classification and evaluation. J Bone Joint Surg (Am), 1970, 52(6): 1077-1089.
5. Stableforth PG. Four-part fractures of the neck of the humerus. J Bone Joint Surg (Br), 1984, 66(1): 104-108.
6. Jakob RP, Miniaci A, Anson PS, et al. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg (Br), 1991, 73(2): 295-298.
7. Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma, 2018, 32 Suppl 1: S1-S170.
8. Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg, 2004, 13(4): 427-433.
9. Laing PG. The arterial supply of the adult humerus. J Bone Joint Surg (Am), 1956, 38-A(5): 1105-1116.
10. Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg (Am), 1990, 72(10): 1486-1494.
11. Brooks CH, Revell WJ, Heatley FW. Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study. J Bone Joint Surg (Br), 1993, 75(1): 132-136.
12. Panagopoulos AM, Dimakopoulos P, Tyllianakis M, et al. Valgus impacted proximal humeral fractures and their blood supply after transosseous suturing. Int Orthop, 2004, 28(6): 333-337.
13. Resch H, Beck E, Bayley I. Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg, 1995, 4(2): 73-80.
14. Resch H, Povacz P, Fröhlich R, et al. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg (Br), 1997, 79(2): 295-300.
15. Foruria AM. Plate fixation of proximal humerus fractures: how to get it right and future directions for improvement. Curr Rev Musculoskelet Med, 2023, 16(10): 457-469.
16. Solberg BD, Moon CN, Franco DP, et al. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma, 2009, 23(2): 113-119.
17. Robinson CM, Longino D, Murray IR, et al. Proximal humerus fractures with valgus deformity of the humeral head: the spectrum of injury, clinical assessment and treatment. J Shoulder Elbow Surg, 2010, 19(7): 1105-1114.
18. Leyshon RL. Closed treatment of fractures of the proximal humerus. Acta Orthop Scand, 1984, 55(1): 48-51.
19. Mills HJ, Horne G. Fractures of the proximal humerus in adults. J Trauma, 1985, 25(8): 801-805.
20. Neer CS 2nd. Displaced proximal humeral fractures. Ⅱ. Treatment of three-part and four-part displacement. J Bone Joint Surg (Am), 1970, 52(6): 1090-1103.
21. Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. J Bone Joint Surg (Am), 2004, 86-A Suppl 1(Pt 2): 143-155.
22. Atalar AC, Eren I, Uludağ S, et al. Results of surgical management of valgus-impacted proximal humerus fractures with structural allografts. Acta Orthop Traumatol Turc, 2014, 48(5): 546-552.
23. 王传舜, 李豪青, 伍凯, 等. 肱骨近端锁定接骨板结合异体骨植骨治疗外翻嵌插型四部分肱骨近端骨折. 中华创伤骨科杂志, 2013, 15(10): 909-911.
24. 菅振, 周建华, 吴良浩, 等. 解剖锁定钢板结合注射式人工骨植骨治疗老年肱骨近端外展嵌插四部分骨折. 中华肩肘外科电子杂志, 2020, 8(2): 140-145.
25. Gunst S, Walch G, Nové-Josserand L. Percutaneous fixation of valgus displaced fracture of the proximal humerus using a single screw. Orthop Traumatol Surg Res, 2018, 104(1): 67-70.
26. Fang C, Kwek EBK. Self-reducing proximal humerus fractures. J Orthop Surg (Hong Kong), 2017, 25(2): 2309499017717180.
27. Bekmezci T, Çepni SK. Subgroups and differences of fixation in 3-part proximal humerus fractures. Ulus Travma Acil Cerrahi Derg, 2023, 29(5): 627-632.
28. 李红军, 刘永国, 王建军, 等. 解剖锁定钢板内固定治疗肱骨近端外翻嵌插型骨折的疗效观察. 中国修复重建外科杂志, 2016, 30(3): 359-362.
29. 王华松, 杨晨曦, 吴刚, 等. 经三角肌入路锁定钢板内固定治疗老年外展嵌插型肱骨近端骨折. 中华创伤杂志, 2020, 36(3): 228-232.
30. 李波, 熊文峰, 张世民. 锁定钢板治疗肱骨近端骨折中螺钉穿透关节面的研究进展. 中国修复重建外科杂志, 2021, 35(4): 403-408.
31. Panagopoulos A, Tatani I, Yannis S, et al. Transosseous suture fixation of true 4-part valgus impacted fractures of the proximal humerus: Clinical and radiological outcome in 49 patients. Open Orthop J, 2018, 12: 41-52.
32. Miquel J, Martínez R, Santana F, et al. Surgical treatment of proximal humeral fractures with the transosseous suture fixation. J Orthop Surg Res, 2021, 16(1): 405.
33. Scheer JH, Tillander BM, Dånmark I, et al. Solely sutures is a reliable fixation for valgus-impacted proximal humeral fractures. J Clin Orthop Trauma, 2021, 15: 130-135.
34. Ju J, Ma M, Ding Z, et al. A transosseous suture as an alternative to suture anchor on anterior-avulsion greater tuberosity fragment fixation in Neer three-part proximal humeral fracture: A biomechanical study. Orthop Surg, 2023, 15(8): 2132-2137.
35. Srinivasan RC, Wright JO, Hao KA, et al. Two-year outcomes of the reverse humeral reconstruction prosthesis. J Shoulder Elbow Surg, 2023, 32(6S): S75-S84.
36. Han PF, Yang S, Wang YP, et al. Reverse shoulder arthroplasty vs. hemiarthroplasty for the treatment of osteoporotic proximal humeral fractures in elderly patients: A systematic review and meta-analysis update. Exp Ther Med, 2022, 24(4): 637.
37. Filho GDRM, Amaral MVG. Shoulder arthroplasty for the treatment of proximal humeral fractures: Current concepts. Rev Bras Ortop (Sao Paulo), 2021, 57(4): 529-539.
38. Weber S, Grehn H, Hutter R, et al. Shoulder arthroplasty for proximal humeral fracture treatment: a retrospective functional outcome analysis. Eur J Orthop Surg Traumatol, 2023, 33(5): 1581-1589.

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